Represented in the medical literature, Ankle fractures are one of the most common skeletal injuries and accounting for approximately 7–10% of emergency department (ED) visits . Traumatic injury of the ankle constitute almost 40% of all sports injuries, which can result in long-term disability and cause substantial negative implication on patient's functional recovery . The appropriate diagnosis and managements of the challenging injuries still remains controversial. Moreover, rapid and large-scale implementation of ERAS program is feasible and effective . Patient-center approach to optimize patients care and experience during the perioperative period, which has been shown to be effective in improving outcomes [12, 13].
Present studies confirmed that standardized ERAS protocols can optimize the outcome of ankle fracture patients. As the major principle of treatment remains to achieve an anatomic reduction and a stable fixation, precise preoperative diagnostics and treatment planning are of great importance. Available literature revealed that combined injuries are common among ankle fracture patients which can result in significant adverse effect. Stenquist et al suggest that patients with any medial tenderness were at significantly higher risk of unstable ankle fracture with instability . Casting or orthosis application non-inferior to cast immobilization is recommended for stable ankle fractures [15–18]. Naumann et al suggested that 6 days would be a safe window for operation that can be used to plan and perform the final operation . While ORIF is an optional strategy for unstable ankle fractures, syndesmosis and deltoid ligament repair may promote fracture union and allows patients to start earlier weight-bearing [20, 21]. Some of the patients accompanied with several combined injuries or dislocation, fortunately, all of them were treated properly and gain satisfied outcomes of rehabilitation.
AOFAS is a powerful tool to evaluate ankle disorders’ function and rehabilitation . We evaluated PROMs by AOFAS at different point after operation at PO3M, PO6M, PO12M, and PO24M. Significant difference of outcomes at PO3M and PO6M were verified. With the numbers available, no significant differences were observed (p>0.05) at PO12M and PO24M were verified between the two groups. However, we notice that better prognosis and tendency in ERAS group in the PO12M. Orthopedic surgeons and rehabilitation physicians often in conjunction together to manage patients with fractures . Some of the researchers believed that special designed devices shown advantages to reduce adverse events and accelerate rehabilitation [24, 25]. One of the significant methods in ERAS is to make proper procedure that including reduction and temporary fixation under emergency anesthesia after the careful evaluation in ED. Patients would obtain early mobility and pain relief through the perioperative management, which is good for accelerate rehabilitation. Multiple linear regression analysis reveals that PO3M and PO6M AOFAS were verified between the two groups (p<0.05). ERAS protocol can improve the outcomes in terms of short-term rehabilitation and we believe that patients will have favorable outcomes when treated by all of these subspecialty providers.
Previous analysis demonstrated that demographic characteristics and procedures may affect the coats and LOS of ankle fracture patients, which has important clinical and economic implications, providing a target for improving patient outcomes [26, 27]. Significant different outcomes were verified (p<0.05) including costs and LOS are associated with ERAS in both univariate analysis and multiple linear regression analysis, which are in line with previous study and confirm the advantages of the ERAS. The finding application of ERAS can reduce the costs and LOS may assist staff and patients pay more attention to the application of ERAS during clinical practice. DRGs payment system was introduced and mandated worldwide for its potential to curbing unnecessary resource and cost-saving implications by decreasing costs and LOS [28, 29]. Relevant literatures reflected that healthcare system assess satisfaction and quality of the inpatients, which highlights the specification of ERAS [30, 31]. Efforts to improve the healthcare should be focused on implementation and enlargement of the DRGs and ERAS.
Traumatic injuries are particularly challenging when they associate skin and soft tissue frail. Perioperative complications are challenges and unsolved problems, underlining the need for further research. In view of frequent recommendations and reports, ERAS protocol has been applicated for many diseases without increasing rate of adverse outcomes [32, 33]. Among all of the patients, no complication was observed in ERAS group. No case caught complication in ERAS group. Two cases in non-ERAS group developed into superficial incision infection and urinary tract infection but were cured with proper procedure. The characteristic of the old, comorbidity, and obesity are more likely to caught complications [34, 35]. Benefit of ERAS application prevent complication is not statistic significant but there exists a tendency in univariate analysis (OR: 0.950, p>0.05, 95% CI, 0.885 to 1.020), which may be limited for small sample.
Ankle fracture can cause post-operative pain but literature is scarce in evaluating opioids consumption in the first 24-hour. Previous study suggested that patients with opioid-related adverse events have greater higher risk of costs and ED visits [36, 37]. By understanding the impact of potential side effect of opioids, we intend to introduce perioperative pain managements but more evidence is needed to demonstrate during clinical practice. Patients would be evaluated after surgery and opioids will be prescribed if VAS ≥ 6. The overall consumption of opioids are similar between two groups in univariate analysis (OR: 0.603, p>0.05, 95% CI, 0.223 to1.630). Moreover, we notice that the number of patients is smaller in ERAS group. Multi-modal analgesia strategies were adopted in ERAS group which may help to improve positive outcomes with better experience and satisfaction. With the direction of ERAS in perioperative plan, we believe ankle fracture patients would benefit more.
Our study has some strengths. To our knowledge, it is the first investigation to confirm the advantages of EARS application among the proper ankle fracture patients at different point after operation. The comprehensive data allowed us to examine the benefits of the ERAS protocol which can improve rehabilitation, quality and efficiency at the early stage. Furthermore, some limitations of the present study should be addressed before making a conclusion. First, the investigation was a retrospective cohort study which is associated with inherent selection bias. Second, we conducted the study with a single-center small database, multiply center giant samples and prospective protocols are needed for further study. Third, the standard of discharge may not be in consistent, which require standard discharge criteria among hospitals. Last but not least, the database did not include information on long-term follow-up outcomes. We believe that prospective studies with long-term follow-up are essential to define the machination clearly and more robust experimental designs are needed to validate the conclusions over time.